Raising awareness of the link between sodium glucose co-transporter 2 inhibitors and euglycaemic diabetic ketoacidosis – an important perioperative consideration

Abstract

Background: Diabetic ketoacidosis (DKA) is a well-recognised medical emergency defined as a biochemical triad of metabolic acidosis, ketosis, and hyperglycaemia. However, when associated with the use of sodium glucose co-transporter 2 (SGLT2) inhibitors, it can pose a diagnostic challenge, presenting without hyperglycaemia as euglycaemic DKA (EDKA).1 Surgery is one of many recognised precipitating factors for this complication, and so it is recommended that SGLT2 inhibitors be withheld during illness and the perioperative period.2 3 With the rising prevalence of diabetes, now estimated to affect almost 500 million people worldwide, the use of SGLT2 inhibitors is becoming more common.4 Improving awareness of the link between EDKA and SGLT2 inhibitors is therefore becoming increasingly important. Methods: Data were collected through an anonymous electronic survey that was distributed amongst all trainees working within the local hospital. This survey asked whether trainees were aware of EDKA and its link to SGLT2 inhibitors and how confident they felt at managing and preventing the condition on a scale of 1 to 5 (1 – not confident at all; 5 – very confident). After subsequent teaching sessions and a Grand Round presentation, a follow-up survey was circulated around trainees. Results: Forty-eight and forty-two responses were received from the pre- and post-intervention surveys, respectively. The pre-intervention survey found that just 42% (n=20) of trainees were aware of EDKA, and only 25% (n=12) were aware of a link with SGLT2 inhibitors. In keeping with this, confidence ratings for managing and preventing EDKA were low with 71% (n=34) of trainees scoring either 1 or 2. After the teaching sessions, the post-intervention survey demonstrated some improvement with 76% (n=32) and 69% (n=29) of trainees reporting greater understanding of both EDKA and its link with SGLT2 inhibitors respectively. Furthermore, trainees reported feeling more confident at managing and preventing EDKA with 60% (n=25) scoring 3 or 4 on the confidence scale. Conclusions: Trainees’ level of awareness around EDKA and its link with SGLT2 inhibitors was initially low. However, there was some improvement after the delivered teaching sessions with scope for further education on this important subject. 1.Musso G, Saba F, Cassader M, Gambino R. BMJ 2020; 371: m41472.Thiruvenkatarajan V, Meyer EJ, Najappa N, Van Wijk RM. Br J Anaesth 2019; 123: 27–363.Medicines and Healthcare products Regulatory Agency. Drug Safety Update, vol 13, issue 8. Mar 2020. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/873524/March-2020-PDF.pdf (accessed 23 Feb 2022)4.Saeedi P, Petersohn I, Salpea P, et al. Diabetes Res Clin Pract 2019; 157: 107843